Provider Demographics
NPI:1699282137
Name:JOHNSON BETHEA, JORDAN BREANNE (BCBA)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:BREANNE
Last Name:JOHNSON BETHEA
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3875 WATERHOLE AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-6733
Mailing Address - Country:US
Mailing Address - Phone:843-240-1371
Mailing Address - Fax:
Practice Address - Street 1:2418 E JOYCE BLVD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4519
Practice Address - Country:US
Practice Address - Phone:479-871-7994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-05
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1-17-28399103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst